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1 PROFESSIONAL SERVICES QUALIFICATION STATEMENT**Professional Services Qualification Statements (PSQS) will be kept on file at the FMERA for two years from the date of submittal of a complete PSQS. An incomplete PSQS will be returned. All items must be completed. If an item is not applicable, indicate so by inserting “N/A”.
Fort Monmouth Economic RevitalizationAuthority
P.O. Box 267Oceanport, NJ 07757
732 720-6350
1. Firm Name/Business Headquarters Address:
Telephone No.:
Fax No.:
E-Mail Address:
2. Submittal Date:
3. Federal ID No.:
4. (a) SIC Code:
(b) NAICS Code:
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5. Type of Ownership:
Total Number of Employees:
Name of Parent Company, if any:
Year Present Firm Established:
Former Firm Name(s) and Year(s) Established:
6. (a) Is the applicant firm certified or registered with the New Jersey Commerce & Economic Growth Commission as an:
Yes ______ No
SBE ______ WBE ______ (Optional) MBE ______ (Optional)
Identification Number:
Attach Certification/Registration form
6. (b) Is the applicant firm registered with the
New Jersey Division of Revenue: ______ Yes ______ No
Attach Business Registration form
7. Principal Contact (include Name, Title and Telephone No.): 8. List Branch Office locations other than Headquarters listed in Item 1:
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9. Check below the discipline for which the applicant firm is submitting its PSQS:(If submitting in more than one area, submit all appropriate documentation for each discipline.)
Boundary/Topographic Survey Services Architectural Design and Programming Services Environmental Engineering
Services & Site Investigation Services Civil Engineering and Geotech Services Planning Services Asbestos Inventory, Integrated Architectural/Engineering Services Construction Inspection Services
Abatement/ASCM Services
10. LIST PRINCIPAL OWNERS: LIST KEY PERSONNEL:
a. Name: a. Name:
b. Home Address: b. Title:
c. Percentage of Ownership:
d. Officer/Title:
a. Name: a. Name:
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b. Home Address: b. Title:
c. Percentage of Ownership:
d. Officer/Title:
a. Name: a. Name:
b. Home Address: b. Title:
c. Percentage of Ownership:
d. Officer/Title:
ATTACH AS MANY SHEETS AS NECESSARY
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11. BRIEF RESUME OF PRINCIPALS AND KEY PERSONNEL
a. Name and Title: a. Name and Title:
b. Years Experience: This Firm Other Firm b. Years Experience: This Firm Other Firm
c. Education: Degree(s)/Year/Specialization/School: c. Education:Degree(s)/Year/Specialization/School:
d. Active Registration: Year First Registered/Discipline/NJ License No.:
d. Active Registration: Year First Registered/Discipline/NJ License No.:
e. Experience and Qualifications: e. Experience and Qualifications:
ATTACH AS MANY SHEETS AS NECESSARY
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12. INSTRUCTIONS:1. Review the Specialty/Discipline Column (Column C) and place an “X” in Column A for those
specialties/disciplines for which the applicant firm is submitting.
2. Review Professional/Technical Staff (Column D) and indicate the number of staff members in the appropriate boxes in Columns E and F working full time for the applicant firm in each specialty/discipline. There is no limit to the number of specialty/discipline on which a staff member may be entered.
3. Indicate the total Professional/Technical Staff for each specialty/discipline in Column G.
*Note: For each specific specialty/discipline, qualified staff must be listed in Column E. Additional credit may be given for any additional staff listed in Column F.
AREQUESTED
B CODE
CSPECIALTY/DISCIPLINE
DPROFESSIONAL/TECHNICAL STAFF
EIN THE OFFICE SUBMITTING
FOFFICES IN
PROXIMITY (WITHIN 100 MILES OF
PRIMARY OFFICE) GTOTAL STAFF
# OF STAFF WITH A NJ LIC-ENSE
# OF ADD’L TECH-NICAL STAFF
# OF STAFF WITH A NJ LICENSE
# OF ADD’L TECH-NICAL STAFF
01 ARCHITECTURE ARCHITECTS
02 ELECTRICAL ENGINEERING ELECTRICAL ENGINEERS
03 HVAC ENGINEERING HVAC ENGINEERS
04 PLUMBING ENGINEERING PLUMBING ENGINEERS
05 CIVIL ENGINEERING CIVIL ENGINEERS
06 SANITARY ENGINEERING SANITARY ENGINEERS
07 STRUCTURAL ENGINEERING STRUCTURAL ENGINEERS
08 DEMOLITION ENGINEERING CIVIL ENGINEERS
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AREQUESTED
B CODE
CSPECIALTY/DISCIPLINE
DPROFESSIONAL/TECHNICAL STAFF
EIN THE OFFICE SUBMITTING
FOFFICES IN
PROXIMITY (WITHIN 100 MILES OF
PRIMARY OFFICE) GTOTAL STAFF
# OF STAFF WITH A NJ LIC-ENSE
# OF ADD’L TECH-NICAL STAFF
# OF STAFF WITH A NJ LICENSE
# OF ADD’L TECH-NICAL STAFF
09 MECHANICAL ENGINEERING (Elevators/Conveyors)
MECHANICAL ENGINEERS
10 SOILS ENGINEERING SOIL ENGINEERS
11 FIRE PROTECTION ENGINEERING
FIRE PROTECTION ENGINEERS
12 ENVIRONMENTAL ENGINEERING
ENVIRONMENTAL ENGINEERS
13 MARINE ENGINEERING CIVIL ENGINEERS
14 LANDSCAPE DESIGN LANDSCAPE ARCHITECTS
15 PLANNING PLANNERS
16 LAND SURVEYING SURVEYORS
17 AERIAL SURVEY SURVEYORS
18 HYDROGRAPHIC SURVEYING SURVEYORS
19 FIRE & LIFE SAFETY RENOVATIONS
ARCHITECTS/ENGINEERS
20 BARRIER FREE/ADA DESIGN ARCHITECTS/ENGINEERS
21 ESTIMATING/COST ANALYSIS ESTIMATORS
22 INTERIOR DESIGN SPACE PLANNING
INTERIOR DESIGNERS
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AREQUESTED
B CODE
CSPECIALTY/DISCIPLINE
DPROFESSIONAL/TECHNICAL STAFF
EIN THE OFFICE SUBMITTING
FOFFICES IN
PROXIMITY (WITHIN 100 MILES OF
PRIMARY OFFICE) GTOTAL STAFF
# OF STAFF WITH A NJ LIC-ENSE
# OF ADD’L TECH-NICAL STAFF
# OF STAFF WITH A NJ LICENSE
# OF ADD’L TECH-NICAL STAFF
23 ROOFING INSPECTION ROOFING INSPECTORS
24 CONSTRUCTION MANAGEMENT
CONSTRUCTION MANAGERS
25 CPM SCHEDULERS
26 ARCHAEOLOGY ARCHAEOLOGISTS
27 GEOLOGY GEOLOGISTS
28 VALUE ENGINEERING ARCHITECTS/ENGINEERS/ESTIMATORS
29 HISTORICAL PRESERVATION/RESTORATION
ARCHITECTS
30 ROOFING CONSULTANT ARCHITECTS/ENGINEERS
31 ACOUSTICS ACOUSTICIANS
32 ASBESTOS ABATEMENT AHERA PROJECT DESIGNERS
DESIGN/CONSTRUCTION/MONITORING
ASBESTOS SAFETY TECHNICIANS
33 CLAIMS ANALYSIS CLAIMS ANALYSTS/ESTIMATORS
34 TELECOMMUNICATIONS TELECOMMUNICATION SPECIALISTS
35 EXHIBIT/INTERPRETATIVE DESIGN
DESIGNERS
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AREQUESTED
B CODE
CSPECIALTY/DISCIPLINE
DPROFESSIONAL/TECHNICAL STAFF
EIN THE OFFICE SUBMITTING
FOFFICES IN
PROXIMITY (WITHIN 100 MILES OF
PRIMARY OFFICE) GTOTAL STAFF
# OF STAFF WITH A NJ LIC-ENSE
# OF ADD’L TECH-NICAL STAFF
# OF STAFF WITH A NJ LICENSE
# OF ADD’L TECH-NICAL STAFF
36 FEASIBILITY/MASTER PLANNING
PLANNERS/ARCHITECTS/ENGINEERS
37 FIRE DETECTION SYSTEMS FIRE DETECTION SPECIALISTS
38 FIRE PROTECTION SYSTEMS FIRE PROTECTION SPECIALISTS
39 FOOD SERVICE FOOD SERVICE CONSULTANTS
40 HYDRAULICS/PNEUMATICS HYDRAULIC ENGINEERS
41 HYDROLOGY HYDRO GEOLOGISTS
42 SECURITY SYSTEMS SECURITY SYSTEM CONSULTANTS
43 SITE PLANNING PLANNERS/ARCHITECTS/ENGINEERS
44 TESTING & BALANCING (HVAC)
HVAC ENGINEERS
45 TRAFFIC TRAFFIC ANALYSTS
46 TRANSPORTATION CIVIL ENGINEERS
47 WASTE/WATER TREATMENT CIVIL/SANITARY ENGINEERS
48 ENERGY MANAGEMENT CONTROL SYSTEMS
HVAC/ELECTRICAL ENGINEERS
49 RADON MANAGEMENT CONSULTANT
DEP CERTIFIED CONSULTANTS
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AREQUESTED
B CODE
CSPECIALTY/DISCIPLINE
DPROFESSIONAL/TECHNICAL STAFF
EIN THE OFFICE SUBMITTING
FOFFICES IN
PROXIMITY (WITHIN 100 MILES OF
PRIMARY OFFICE) GTOTAL STAFF
# OF STAFF WITH A NJ LIC-ENSE
# OF ADD’L TECH-NICAL STAFF
# OF STAFF WITH A NJ LICENSE
# OF ADD’L TECH-NICAL STAFF
50 CONSTRUCTION FIELD INSPECTION
FIELD INSPECTORS
51 ELEVATOR PLAN REVIEW, TESTING INSP.
DCA CERTIFIED SPECIALISTS
52 ENVIRONMENTAL CONSULTANT
ENVIRONMENTAL SPECIALISTS/SCIENTISTS
53 UNDERGROUND STORAGE TANK REMOVAL/INSTALLATION
DEP CERTIFIED SPECIALISTS (SSE)
54 BOILER/STEAM LINES ENGINEERS
55 AIR QUALITY INDUSTRIAL HYGIENISTS
56 LANDFILL CLOSURE ENVIRONMENTAL ENGINEERS
57 LEAD PAINT EVALUATION/INSPECTION
DOH CERTIFIED TECH (DCA FIRM CERTIFIED)
58 COMPUTER PROGRAMMER/OPERATOR
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13. RANK ORDER OF APPLICANT FIRM'S EXPERTISE FOR VARIOUS BUILDING TYPES FROM 1 TO 20 (1=HIGHEST). DO NOT USE ANY NUMBER MORE THAN ONCE. IF APPLICANT FIRM HAS NO EXPERIENCE IN A PARTICULAR BUILDING TYPE, WRITE “NONE”.
RANK ORDER CODE BUILDING TYPE RANK ORDER CODE BUILDING TYPE
59 CHILD CARE FACILITIES 69 MEDICAL FACILITIES
60 RADIO/TV FACILITIES 70 OFFICE FACILITIES
61 COMPUTER FACILITIES 71 PARKS
62 CORRECTIONAL FACILITIES 72 RECREATIONAL FACILITIES
63 DAMS, DIKES, LEVEES 73 RESIDENTIAL
64 EDUCATIONAL FACILITIES 74 SITE ENGINEERING/ROADWAY/PAVING
65 LABORATORIES/RESEARCH FACILITIES 75 THEATERS
66 LIBRARIES MUSEUMS 76 WAREHOUSE/INDUSTRIAL FACILITIES
67 MAINTENANCE FACILITIES 77 WASTE/WATER TREATMENT FACILITIES
68 MARINAS, DOCKS, BULKHEADS 78 HISTORIC PRESERVATION
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14. (A) PROJECT EXAMPLES - LIST A VARIETY OF PROJECTS COMPLETED OVER THE PAST TEN (10) YEARS. A MINIMUM OF FIVE (5) PROJECTS MUST BE LISTED. IT IS ADVISABLE TO LIST PROJECTS IN ORDER TO SUPPORT THE APPLICANT FIRM'S REQUESTED SPECIALTY/DISCIPLINE.
* "P" INDICATES SERVICES PERFORMED AS A PRIME CONSULTANT. "S" INDICATES SERVICES PERFORMED AS A SUB-CONSULTANT TO A PRIME. "JV" INDICATES SERVICES PERFORMED AS PART OF A JOINT VENTURE.
SPECIALTY TYPE (CODE NUMBER)
* "P", "S", OR "JV"
PROJECT NAME AND LOCATION PROJECT OWNER: NAME, ADDRESS,PHONE NUMBER & E-MAIL
PROJECT REPRESENTATIVE: NAME, ADDRESS, PHONE NUMBER & E-MAIL
CONSTRUCTION COST (IN THOUSANDS) &TOTAL SQUARE FOOTAGE &/OR ACREAGE
TOTAL COST OF WORK FOR WHICH FIRM WAS RESPONS-IBLE
YEAR WORK COMP-LETE
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SPECIALTY TYPE (CODE NUMBER)
* "P", "S", OR "JV"
PROJECT NAME AND LOCATION PROJECT OWNER: NAME, ADDRESS,PHONE NUMBER & E-MAIL
PROJECT REPRESENTATIVE: NAME, ADDRESS, PHONE NUMBER & E-MAIL
CONSTRUCTION COST (IN THOUSANDS) &TOTAL SQUARE FOOTAGE &/OR ACREAGE
TOTAL COST OF WORK FOR WHICH FIRM WAS RESPONS-IBLE
YEAR WORK COMP-LETE
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14. (B) TO BE COMPLETED ONLY IF RESPONDING TO A SPECIFIC ADVERTISEMENT. LIST PROJECT EXAMPLES WHICH BEST ILLUSTRATE THE APPLICANT FIRM’S CURRENT QUALIFICATIONS RELEVANT TO THE ADVERTISED PROJECT OF SIMILAR SIZE AND SCOPE OVER THE PAST TEN (10) YEARS. A MINIMUM OF FIVE (5) PROJECTS MUST BE LISTED.
* "P" INDICATES SERVICES PERFORMED AS A PRIME CONSULTANT. "S" INDICATES SERVICES PERFORMED AS A SUB-CONSULTANT TO A PRIME. "JV" INDICATES SERVICES PERFORMED AS PART OF A JOINT VENTURE.
SPECIALTY TYPE (CODE NUMBER)
* "P", "S", OR "JV"
PROJECT NAME AND LOCATION PROJECT OWNER: NAME, ADDRESS,PHONE NUMBER & EMAIL
OWNER’S REPRSENTATIVE: NAME, ADDRESS, PHONE NUMBER & EMAIL
CONSTRUCTION COST (IN THOUSANDS) &TOTAL SQUARE FOOTAGE &/OR ACREAGE
TOTAL COST OF WORK FOR WHICH FIRM WAS RESPONSIBLE
YEAR WORK COMP-LETE
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SPECIALTY TYPE (CODE NUMBER)
* "P", "S", OR "JV"
PROJECT NAME AND LOCATION PROJECT OWNER: NAME, ADDRESS,PHONE NUMBER & EMAIL
OWNER’S REPRSENTATIVE: NAME, ADDRESS, PHONE NUMBER & EMAIL
CONSTRUCTION COST (IN THOUSANDS) &TOTAL SQUARE FOOTAGE &/OR ACREAGE
TOTAL COST OF WORK FOR WHICH FIRM WAS RESPONSIBLE
YEAR WORK COMP-LETE
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15. GROSS FEES (in thousands) FROM CONTRACTS ENTERED INTO IN THE LAST TEN (10) YEARS:
From All Entities From State Government From Local Government From Federal Comments (Inc. Private Sector) Entities Entities Government Entities
Year(Most Recent)
Year
Year
Year
Year
YearYear
Year
Year
Year
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16. FINANCIAL STATEMENT INFORMATION:Audited Financial Statements are preferred for all applicants. Note: Firms that do not have Audited Financial Statements, may submit Reviewed Financial Statements. Small firms which do not have Audited or Reviewed Financial Statements, may submit Compilations. However, the following information at a minimum is required in each category.
Audited Financial Statements for last two years including:- Auditor’s Reports- Balance Sheets- Statements of Income and Retained Earnings- Statement of Cash Flows- All footnotes to these statements
Corporate Annual Report (if applicable)
Reviewed Financial Statements for last two years including:- Balance Sheets- Statements of Income and Retained Earnings- Statement of Cash Flows- All footnotes to these statements
Compilations for last two years including:- Balance Sheets- Statements of Income and Retained Earnings- Statement of Cash Flows- All footnotes to these statements
Federal Tax Returns
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17. DISCLOSURE:
(A) Is the applicant firm identified in Box 1 of this PSQS owned by another company or firm? (If yes, please complete a separate disclosure form for the parent company.)
(B) Within the past 5 years, has the applicant firm been owned by another company or firm? (If yes, please complete a separate disclosure form for the parent company.)
(C) Have any principals listed in this Qualification Statement ever been arrested, charged, indicted or convicted of a crime? (If yes, attach an
explanation for each instance.)
(D) Has any person or entity listed in this Qualification Statement ever been suspended, debarred or otherwise declared ineligible, by any agency of government, from contracting to provide services, labor, material or supplies? (If yes, attach an explanation for each instance.)
(E) Has any federal, state or local government license, permit or other similar authorization necessary to perform the work applied for herein, and held or applied for by any person or entity listed in this Qualification Statement been suspended or revoked, or is the subject of any pending proceedings specifically seeking or litigating the issue of suspension or revocation? (If yes, attach an explanation for each instance.)
(F) Are there currently any administrative, civil or criminal matters pending in any federal, state or local government jurisdiction in which the applicant firm or its principals or key personnel are involved? (If yes, attach an explanation for each instance.)
(G) Has the applicant firm been denied pre-qualification from any other state or federal entity in the past five years under this name or another? (If yes, attach an explanation for each instance.)
(H) At present or during the past 5 years, have any of the principals or key personnel of the applicant firm served as a principal or key personnel or owned 5% or more of any other firm (including firms that are inactive or have been dissolved)? (If yes, give name, name of firm, position held, % owned, remainder owned by, and dates owned.)
(I) Has the applicant firm, its affiliate or any of its principals or key personnel been a party to a bankruptcy or re-organization proceeding? (If yes, provide caption, date, docket number, court and county.)
(J) In the past 5 years, has the applicant firm, or any of its affiliate firms: (If yes to any of the following, attach explanation.)
(A) had a contract terminated?(B) been given a final unsatisfactory performance rating on a specific project?(C) had liquidated damages assessed against it in connection with a contract?
YES NO
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(D) engaged in any litigation with regard to any contract?
(K) Do any of the principals of the applicant firm have an ownership interest in any other entity which is in the same line of business for which the applicant firm has submitted its PSQS? (If yes, identify the name, address and federal tax ID number for such entity and the nature of the ownership interest.)
18. INSURANCE: Identify insurance policies currently held by the applicant firm:(For each policy, name the following: policy limits, expiration date, carrier, agent, agent name, address, and phone number.)
GENERAL LIABILITY:
EXCESS LIABILITY:
PROFESSIONAL LIABILITY:
ENVIRONMENTAL LIABILITY:
AUTOMOBILE:
MULTIPLE PERIL:
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WORKERS COMPENSATION:
OTHER:
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19. Within this space, the applicant firm may provide any additional information or description of resources supporting the applicant firm’s qualifications, including achievements and awards received during the past 5 years.
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20. CERTIFICATION:
This certification must be completed by each current Principal of the applicant firm identified in Box 10. Certifications must be notarized when signed.
A MATERIAL FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS PSQS WILL SUBJECT THE APPLICANT FIRM TO CIVIL AND CRIMINAL PENALTIES AVAILABLE AT LAW.
I, ____________________________________ (name) being duly sworn, state that I am _________________________ (title) of ____________________________, (firm name) and that I have read and understand the questions contained in this PSQS and its attachments, if any.
I certify that to the best of my knowledge the information given in response to each question and the attachments is full, complete and truthful.
I acknowledge that the Fort Monmouth Economic Revitalization Authority may, by means it deems appropriate, determine the accuracy and truth of the statements made in this PSQS.
I recognize that all of the information submitted is for the express purpose of inducing the Fort Monmouth Economic Revitalization Authority to evaluate the applicant firm’s qualifications and/or allow the applicant firm to participate in professional service consultant contracts and that the Fort Monmouth Economic Revitalization Authority will rely on the information submitted in this PSQS.
I agree and warrant that truthfully answering the questions in this PSQS is an event entirely within my control.
I understand and agree that this PSQS and all supporting documentation filed with the Fort Monmouth Economic Revitalization Authority shall become the property of the Fort Monmouth Economic Revitalization Authority and shall be subject to disclosure as a public record.
I understand and agree that this PSQS will be kept on file at the Fort Monmouth Economic Revitalization Authority for a period of 2 years from the date of submittal of a complete PSQS. I understand that the Fort Monmouth Economic Revitalization Authority is under no obligation to contact the applicant firm upon the expiration of the 2 year period. I acknowledge that a current PSQS must be submitted to the Fort Monmouth Economic Revitalization Authority by the applicant firm every 2 years.
I authorize the Fort Monmouth Economic Revitalization Authority to contact any entity or person named in this PSQS for purposes of verifying the information supplied by the applicant firm.
Sworn to before me this ______ day of _____________________, ____ _____________________________________________________________
Name, Title (print or type)
_________________________________________ _____________________________________________________________
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Notary Public Signature/Date
ATTACH AS MANY SHEETS AS NECESSARY
I BEING DULY SWORN UPON MY OATH, HEREBY REPRESENT AND STATE THAT THE FOREGOING INFORMATION AND ANY ATTACHMENTS THERETO, TO THE BEST OF MY KNOWLEDGE, ARE TRUE AND COMPLETE. I ACKNOWLEDGE THAT THE FORT MONMOUTH ECONOMIC REVITALIZATION AUTHORITY IS RELYING ON THE INFORMATION CONTAINED HEREIN AND THEREBY ACKNOWLEDGE THAT I AM UNDER A CONTINUING OBLIGATION FROM THE DATE OF THIS CERTIFICATION THROUGH THE COMPLETION OF ANY CONTRACTS WITH THE FORT MONMOUTH ECONOMIC REVITALIZATION AUTHORITY TO NOTIFY THE FORT MONMOUTH ECONOMIC REVITALIZATION AUTHORITY IN WRITING OF ANY CHANGES TO THE ANSWERS OR INFORMATION CONTAINED HEREIN. A MATERIAL FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS PSQS WILL SUBJECT THE APPLICANT FIRM AND ME TO CIVIL AND CRIMINAL PENALTIES AVAILABLE AT LAW. I AUTHORIZE THE FORT MONMOUTH ECONOMIC REVITALIZATION AUTHORITY TO VERIFY ANY ANSWER(S) CONTAINED HEREIN, TO INVESTIGATE MY BACKGROUND AND CREDIT WORTHINESS AND OF THE APPLICANT FIRM AND TO ENLIST THE AID OF THIRD PARTIES IN ITS INVESTIGATIVE PROCESS.
I, BEING DULY AUTHORIZED, CERTIFY THAT THE INFORMATION SUPPLIED IN THIS PSQS, INCLUDING ALL ATTACHMENTS, IS COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Sworn to before me this ______ dayof _____________________, ____ _____________________________________________________________
Name, Title (print or type)
_________________________________________ _____________________________________________________________Notary Public Signature/Date
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Submittal:
Firms interested in submitting a PSQS to the Fort Monmouth Economic Revitalization Authority should submit one (1) copy via email and/or electronic submittal of the fully completed “Professional Services Qualification Statement" to the following address:
Fort Monmouth Economic Revitalization AuthorityP.O. Box 267
Oceanport, NJ 07757Attn: Regina McGrade
Email address: [email protected] (please use this email address if submitting PSQS electronically)Firms submitting in more than one discipline must include all appropriate supporting documentation for each discipline.PLEASE NOTE, IF SUBMITTING IN RESPONSE TO A PUBLIC ADVERTISEMENT, ELECTRONIC SUBMISSION IS NOT ACCEPTABLE. PLEASE CONSULT THE PUBLIC ADVERTISEMENT FOR SPECIFIC SUBMISSION REQUIREMENTS.
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